Before you refer someone to Restitute, please confirm you have: *

• Sent a copy of our leaflet to the client
• Spoken to them about the service and explained what we offer
• Considered the timing of the referral and the client's readiness
• Completed ONE form for each adult being referred

Client's name *

First

Last

Client's date of birth *

Any other name the client is known by

Client's phone number *

Client's Email *

First line of client's address *

Client's Postcode *

If you don't know the client's postcode, please state the nearest town.

Why are you making this referral? Please provide any details that your client has agreed you can share.

What can you tell us about other family members? For example, other carers

Demographics

If you know the following information about the person you are referring, it would help enormously if you can provide it here:

Gender: Is the person you're referring:

• Male
• Female
• Non-binary
• Prefer not to say
• Other

Sexuality: Is the person you're referring:

• Bisexual
• Heterosexual or Straight
• Gay or Lesbian
• Not known
• Other sexual orientation

Ethnicity: Is the person you're referring

• Asian / British Indian
• Asian / British Pakistani
• Asian / British Bangladeshi
• Asian / British Chinese
• Any other Asian background
• Black / Black British Caribbean
• Black / Black British African
• Any other Black, Black British, or Caribbean background
• Mixed or multiple ethnic groups
• Mixed White and Black Caribbean
• Mixed White and Black African
• Mixed White and Asian
• Any other Mixed or multiple ethnic background
• White English, Welsh, Scottish, Northern Irish or British
• White Irish
• Gypsy or Irish Traveller
• Roma
• Any other White background

My pronouns are:

• He/Him
• She/Her
• They/Them
• We/Us
• Something different

We are only able to accept referrals for 3rd party victims of crime. Please indicate if the person you are referring is the: *

• Parent
• Partner / Spouse
• Other relative
• Carer
• Friend

About the referrer

How did you hear about Restitute? *

Organisation name

Contact name *

First

Last

Email *

Telephone number

Apart from your organisation, who else is involved with your client?

• Police
• Social Care Services
• Independent Sexual Violence Advocate
• Independent Domestic Violence Advocate
• Other organisation
• None

GDPR Agreement *

• My client consents to Restitute storing their submitted information.

Consent to contact *

• My client is aware that Restitute will contact them via email once this form is submitted.

Please ask your client to add @restitute.org as a safe sender.

Website

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